DEPARTMENT
The Child With Pediculosis
Capitis
Robert J. Yetman, MD
KEY WORDS
Child, head lice, diagnosis, treatment
BACKGROUND
Pediculosis capitis is an extraordinarily common hu-
man parasitic infestation, with millions of infestations
occurring each year. Despite the prevalent myth that
this condition is associated with poverty (dirty hair),
all socioeconomic classes are affected, and head lice
actually prefer healthy hosts with clean hair
(Centers for Disease Control and Prevention [CDC],
2013; Frankowski & Bocchini, 2010; Hodgdon et al.,
2010; Meinking & Taplin, 2011).
Section Editors
Robert J. Yetman, MD
Corresponding Editor
University of Texas School of Medicine
Houston, Texas
Polly F. Cromwell, MSN, RN, CPNP
Yale-New Haven Childrens Hospital
Bridgeport Hospital Campus
Bridgeport, Connecticut
Robert J. Yetman, Professor of Pediatrics, University of Texas
School of Medicine, Houston, TX.
Conflicts of interest: None to report.
Correspondence: Robert J. Yetman, MD, Department of Pediatrics,
JJ495, University of Texas School of Medicine, 6431 Fannin,
Houston, TX 77030; e-mail: Robert.J.Yetman@uth.tmc.edu.
J Pediatr Health Care. (2015) 29, 118-120.
0891-5245/$36.00
Copyright Q 2015 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
Published online October 24, 2014.
http://dx.doi.org/10.1016/j.pedhc.2014.09.002
118 Volume 29  Number 1
Practice Guidelines
The adult louse is small (2 to 3 mm long) and usually
pale gray in color unless engorged with blood, when
they will appear red or brown. They feed every few
hours by injecting small amounts of their saliva
into the hosts skin and withdrawing a tiny amount of
blood. They usually do not subsist away from the
warmth of the scalp, usually surviving less than a
day (Frankowski & Bocchini, 2010; Meinking &
Taplin, 2011).
HISTORY AND SYMPTOMS
 The life cycle of the head louse is as follows:
 The female lays the first egg 1 or 2 days after
mating and can lay about 10 eggs per day
 The egg is tightly attached to the hair shaft and
close to the scalp
 Eggs hatch in 7 to 12 days
 The louse goes through three nymph stages and
becomes an adult 9 to 12 days after hatching
 Females live 3 to 4 weeks as the cycle repeats
(Frankowski & Bocchini, 2010; Meinking &
Taplin, 2011)
 Transmission typically occurs by:
 Head to head contact with an infected person
 Indirect spread via combs, brushes, hats, or
other personal items, although this occurrence
is less likely than direct contact
 Itching as a symptom of infection may take 4 to 6
weeks to begin for the first infection but may
develop within 48 hours in someone with a previ-
ous infestation
 Excoriation, crusting, and secondary bacterial
infection may result from scratching (CDC,
2013; Frankowski & Bocchini, 2010; Meinking
& Taplin, 2011)
EVALUATION
Physical Examination
 Careful inspection of the hair is need for proper
diagnosis
 Definitive diagnosis
Journal of Pediatric Health Care
 - Finding a live louse or nymph on the scalp
or head
 In a patient who has been treated for lice, nits
attached more than 1 cm from the scalp typically
are nonviable, although in warmer climates
viable nits may be found up to several inches
from the scalp (CDC, 2013; Frankowski &
Bocchini, 2010; Paller & Mancini, 2011)
 Careful evaluation for secondary bacterial infec-
tion is warranted
 Secondary bacterial infection is uncommon in
the United States, but streptococcal or staphylo-
coccal pyoderma is possible
 The pyoderma often improves upon the treat-
ment of the head lice even without the use of
antibiotics (Meinking & Taplin, 2011)
Laboratory Studies
 Laboratory studies typically are not needed
DIFFERENTIAL DIAGNOSIS
The differential diagnosis is as follows (American
Academy of Pediatrics [AAP], 2012; Frankowski &
Bocchini, 2010; Paller & Mancini, 2011):
 Dandruff
 Fibers
 Scabs
 Hair casts
 Droplets of hair spray
 Plugs of desquamated cells
 Dirt particles
 Home remedies, the value of which have not been
 Fungus
MANAGEMENT
 Many patients diagnoses are made by a school
nurse, parent, or caregiver, and others are made
by another health care provider. Often a first-line,
appropriately applied over-the-counter remedy is
attempted in geographic areas with a low inci-
dence of lice resistance. Unfortunately, the areas
of low resistance are unknown, and generally
high rates of resistance across the United States
make the effectiveness of these over-the-counter
medications highly suspect. In many areas of the
United States, prescription medications are first-
line therapies.
 Over-the-counter options
 Permethrin (Nix; CDC, 2013)
- Approved for use in children older than 2
months
- Application time is 10 minutes; retreatment
in 14 days is recommended if new lice are
seen
 Pyrethrins with piperonyl butoxide (Rid; CDC,
2013)
www.jpedhc.org
- For use in children older than 2 years
- Application time is 10 minutes; retreatment
is 7 to 10 days is required
 Prescription options
 Lindane 1% shampoo (Lindane, 2014)
- To be used with caution in children who
weigh less than 50 kg (110 lb)
- Application time is 4 minutes; no retreat-
ment is recommended
 Malathion 0.5% lotion (Ovide; TaroPharma,
2011)
- No safety data in children younger than 6
years
- Application time is 8 to 12 hours with repeat
treatment in 7 to 9 days if lice are present
 Benzyl alcohol 5% lotion (Ulesfia; Concordia
Pharmaceuticals, 2013)
- Used in children 6 months and older
- Application time is 10 minutes with retreat-
ment after 7 days
 Spinosad 0.9% (Natroba; ParaPRO LLC, 2011)
- Approved for use in children older than 4
years
- Application time is 10 minutes with retreat-
ment in 7 days if lice are present
 Ivermectin 0.5 lotion (Sklice; Sanofi Pasteur,
2012)
- Approved for use in children 6 months and
older
- Application time is 10 minutes; retreatment
is not recommended
systematically evaluated
 Natural products
- Essential oils and plant extracts
- Occlusive agents such as mayonnaise, pe-
troleum jelly, tub margarine, or Cetaphil
cleanser
- Vinegar and vinegar-based products
(Frankowski & Bocchini, 2010)
 Mechanical removal of nits and lice
- Demethicone gel (LiceMD, 2014), citric
acid/isopropanol (Lycelle; Mission
Pharmacal Company, 2011)
h Does not kill lice or nits, but rather the
mechanism of action is to allow easier
removal of the nits and lice
- Nitpicking salons
h Usually a storefront location where the
child with head lice is brought to have
a franchise employee mechanically
comb through the hair, identify each
nit or louse, and remove it mechanically
h Advertised as a natural approach to lice
and nit removal that mechanically
remove the live lice and nits
January/February 2015 119

BOX. Resources for the diagnosis and
treatment of head lice
Centers for Disease Control and Prevention
 http://www.cdc.gov/parasites/
American Academy of Dermatology, Parent Resources
 http://www.kidsskinhealth.org/grownups/lice.html
WebMD, Head Lice Slide Show: What Parents Should
Know
 http://children.webmd.com/ss/slideshow-lice-overview
h Comb-out process that might include Centers for Disease Control and Prevention. (2013). Head lice.
application of natural oils and shampoos
to hasten removal of nits, as well as
controlled hot air applications to help
identify live lice (Goats et al., 2006)
REFERRAL
 To a pediatric dermatologist for:
 Definitive diagnosis in challenging or confusing
cases
 Treatment options in situations where
first- and second-line therapies fail despite
confirmation that appropriate application was
performed
EDUCATION
 Parents should be educated on true findings asso-
ciated with lice infestation to avoid misdiagnosis
due to contact or seborrheic dermatitis, eczema,
psoriasis, insect bites, or fungus. Encourage
involvement of the health care professional to
correctly make the diagnosis so appropriate treat-
ment can be initiated (CDC, 2013; Frankowski &
Bocchini, 2010; Meinking & Taplin, 2011).
 Attempts to determine local resistance patterns may
be helpful. Generally, high rates of resistance to
over-the-counter medications limit their usefulness.
 Work with local schools to eliminate inappropriate
no nit policies that preclude student attendance
if nits are present in the hair. The AAP (2012), the
National Association of School Nurses (Pontius &
Teskey, 2011) and the American School Health
Association (2005) have recommended abandon-
ment of no nit policies.
 Teach families control measures:
 Wash in hot water (or dry clean) all recently used
clothing, hats, bedding, and towels
 Wash in hot water all combs, brushes, hair clips,
and the like that may have been exposed to the
affected hair
120 Volume 29  Number 1
 Place items that cannot be washed or dry
cleaned in sealed bags for 2 weeks
 Have other family members evaluated for the
presence of live lice or nits so that all affected
family members can be treated simultaneously
 See the Box for parent resources
REFERENCES
American Academy of Pediatrics. (2012). Pediculosis capitis (head
lice). In L. K. Pickering (Ed.), Red book: 2012 Report of the Com-
mittee on Infectious Diseases (29th ed., pp. 543-546). Elk Grove
Village, IL: American Academy of Pediatrics.
Retrieved from http://www.cdc.gov/parasites/lice/head/index.
html
Centers for Disease Control and Prevention. (2013). Head lice informa-
tion for schools. Retrieved from http://www.cdc.gov/parasites/
lice/head/schools.html
Concordia Pharmaceuticals. (2013). Ulesfia prescribing information.
Retrieved from http://www.ulesfialotion.com/pdf/Ulesfia_
Prescribing_Information.pdf
Frankowski, B. L., Bocchini, J. A. & Council on School Health and
Committee on Infectious Diseases. (2010). Head lice: Clinical
report. Pediatrics, 126, 392-403.
Goats, B. M., Atkin, B. A., Wilding, B. S., Birch, K. G., Cottam, M. R.,
Bush, S. E., & Clayton, D. H. (2006). An effective nonchemical treat-
ment for head lice: A lot of hot air. Pediatrics, 118(5), 1962-1967.
Hodgdon, H. E., Yoon, K. S., Previte, D. J., Kim, H. J., Aboelghar,
G. E., Lee, S. H., & Clark, J. M. (2010). Determination of knock-
down resistance allele frequencies in global human head louse
populations using the serial invasive signal amplification reac-
tion. Pest Management Science, 66, 1031-1040.
LiceMD. (2014). Pediculicide lice treatment. Retrieved from http://
www.licemd.com/pediculicide-lice-treatment.php
Lindane Prescribing Information. (2014). Retrieved from http://
www.versapharm.com/media/productinserts/PI_Lindane_
Shampoo.pdf
Meinking, T., & Taplin. (2011). Infestations. In L. A. Schachner &
R. C. Hansen (Eds.), Pediatric dermatology (4th ed, pp. 1525-
1583). Philadelphia, PA.: Mosby Elsevier.
Mission Pharmacal Company. (2011). Lycelle head lice removal
kit. Retrieved from http://www.missionpharmacal.com/sites/
default/files/package_inserts/lycelle_0.pdf
Paller, A. S., & Mancini, A. J. (2011). Lice (pediculosis). In: Hurwitz
clinical pediatric dermatology: A textbook of skin disorders of
childhood and adolescence (4th ed., pp. 424-427). New
York, NY: Elsevier Saunders.
ParaPRO LLC. (2011). Natroba prescribing information. Retrieved
from http://natroba.com/Full%20Prescribing%20Information.
pdf
Pontius, D., & Teskey, C. (2011). Pediculosis management in the school
setting. Retrieved from http://www.nasn.org/PolicyAdvocacy/
PositionPapersandReports/NASNPositionStatementsFullView/
tabid/462/ArticleId/40/Pediculosis-Management-in-the-School-
Setting-Revised-2011
Sanofi Pasteur. (2012). Sklice lotion prescribing information.
Retrieved from http://products.sanofi.us/Sklice/Sklice.pdf
TaroPharma. (2011). Ovide prescribing information. Retrieved from
http://www.tarousa.com/media/oMedia/Ovide%20(malathion)%
20Lotion.pdf
Journal of Pediatric Health Care